Adam Hurewitz’s research while affiliated with Winthrop University Hospital and other places

Aggressive weight-based dosing guidelines help achieve prompt therapeutic anticoagulation in patients with venous thromboembolism (VTE). While obese patients with VTE face an increased risk of recurrence, physicians typically resist prescribing doses two to three times the usual dose because of concern about bleeding complications. To examine the use of unfractionated heparin in obese patients with VTE at an academic teaching hospital in order to document the extent and pattern of underprescribing in this high-risk patient population. Three-year, cross-sectional consecutive case series. Adult inpatients with VTE and a body mass index ≥30 kg/m(2) who were treated with unfractionated heparin. Time to achievement of therapeutic anticoagulation (activated partial thromboplastin time >60 s) and gap between recommended and prescribed heparin doses. Time to attainment of therapeutic anticoagulation exceeded 24 h in 29% of study patients (n = 84) and exceeded 48 h in 14% of patients. In 75 patients (89%), the prescribed bolus dose fell below the recommended dose of 80 units/kg, and in 64 patients (76%) the initial continuous infusion fell more than 100 units/h below--in some cases more than 1000 units/h below--the recommended dose of 18 units/kg/h. There was a significant correlation between time to therapeutic anticoagulation and initial infusion dose (Spearman r = -0.27; p < 0.02). Each decrease of 1 unit/kg/h translated to a delay ranging from about 0.75 h to 1.5 h over the range of prescribed doses (6 to 22 units/kg/h). A substantial proportion of obese patients treated with unfractionated heparin experienced a delay >24 h in achieving adequate anticoagulation, and the vast majority received an inadequate heparin bolus or initial continuous infusion (or both) according to current dosing guidelines.

Chronic lung diseases are typically associated with impaired quality of life, stress, and anxiety. Written disclosure therapy (WDT) reduces stress in patients with a variety of chronic illnesses. We sought to determine whether WDT benefits patients with chronic lung disease. A prospective, randomized, controlled trial was performed to evaluate the effect of using WDT in patients (N = 66) participating in a pulmonary rehabilitation program. Patients were randomly assigned to write about a particularly traumatic life event (WDT group) or to write about an emotionally neutral subject (control group). Exercise capacity, dyspnea and quality of life, and values of spirometry were recorded at baseline, at the end of the program, and at 6 months. The 6-minute walk distance (6MWD) significantly improved in both groups at 2 months, from 278 to 327 m in WDT and from 269 to 314 m in control groups (P < .01 in both groups). There was no difference in improvement in 6MWD between groups (P = .88). At 6 months, the gains made in 6MWD were no longer present. Dyspnea severity, as well as most of the other domains of the Chronic Respiratory Disease Questionnaire and the St. George's Respiratory Questionnaire, showed improvement within each group, but not between WDT and control groups. WDT did not add any additional benefit in patients with chronic obstructive pulmonary disease or idiopathic pulmonary fibrosis when included as a component of pulmonary rehabilitation. These results are in contrast to previously seen benefits in patients with asthma.

PURPOSE: CT pulmonary angiography (CTPA) is the preferred diagnostic modality for pulmonary embolism (PE) in many institutions. With no additional contrast, CT venography (CTV) can be used to detect deep vein thombosis (DVT). We hypothesized that the transition from nuclear lung scans (V/Q scan) to contrast CT scans increases the capacity to diagnose PE that otherwise might remain undetected. METHODS: We retrospectively examined the records of all patients who were evaluated with either CTPA/CTV or V/Q scans at a University teaching Hospital, accumulating data only for the month of January from 1998-2007. Demographic and radiographic data were analyzed. All V/Q scans with indeterminate readings were independently reviewed by one of us (DK). RESULTS: Over the past 10 years, the number of CTPA studies increased from 15 to 138 per month whereas the number of V/Q studies fell from 74 to 7 per month. The total number of PE diagnosed by either test progressively increased and was twice as large in Jan 2007 (20/month) as in Jan 1998 (10/month). During this same interval the diagnostic yield of CTPA remained relatively constant (11%±1, mean±SEM; range 7-18%). CONCLUSION: We observed a trend to increased testing for suspected PE, primarily as a consequence of increased requests for CTPA/CTV. In 2007, the number of positive studies for PE and DVT doubled when compared with ten years earlier. One possible explanation is that the true incidence of VTE has increased. More likely, a combination of increased clinical suspicion plus the ready availability and enhanced quality of CT multidetector scanners has resulted in improved clinical detection of VTE. CLINICAL IMPLICATIONS: While it is widely recognized that as many as 70-80% of cases of PE are undetected, the increased accuracy of CTPA/CTV compared with V/Q scanning may significantly improve the clinical detection of this treatable but potentially fatal disease. DISCLOSURE: Adam Hurewitz, None.

PURPOSE: We evaluated characteristics of asthma care and documentation by pediatricians (P), pediatric pulmonologists (PP), adult pulmonologists (AP) and allergists (A) at an academic medical center. METHODS: Practice habits and documentation was extracted from 120 charts randomly chosen from each practice. 4 charts were dropped from pediatrics <6 years of age (too young for objective testing). Pediatrics n= 26; Allergy n=30; Adult pulmonary n=30; Pediatric Pulmonary n=30; Total n= 116. RESULTS: Use of controller medications (inhaled steroids & or leukotriene inhibitors) was documented in 73% of (P), 87% of (A); 93% of (AP) and 93% (PP). For those patients whose asthma was classified (n=62) there was an increasing trend to use inhaled steroids as asthma severity increased (p<0.001). Objective testing: *Peak flow use varied between practices. 0% of (PP) patients compared to 97% of (A) patients. *Spirometry testing was mostly performed by (AP) 97% and 100% of (PP) patients. *Full PFT's: 0% of (P); 86% of (A); 27% of (AP) and 24% of (PP) patients had them (p<.0001). Pediatricians do the least amount of asthma office testing, but they referred the most (92%). *Asthma action plans were rarely documented (13%) of (PP) charts (p<0.004). CONCLUSION: The delivery and documentation of patient care varies greatly by practice. *Pediatricians tended to use less controller medications. Allergists used the least amount of leukotriene inhibitors. *All practices documented increasing use of inhaled steroids based on the severity of asthma. Despite the widespread requirement to classify asthma according to the NHLBI guidelines, this is rarely performed and documented in the practice settings of allergists or pulmonary specialists.* Hardly anyone uses asthma action plans. CLINICAL IMPLICATIONS: Many agencies require the use of classifying asthma severity according to the guidelines, using peak flows and formulating asthma action plans. However,it was not documented with any consistency in the practices reviewed. DISCLOSURE: Grace Trimmer, None.

PURPOSE: To determine whether CTPA accurately portrays right ventricular (RV) and pulmonary artery (PA)dilatation and to correlate these findings with echocardiographic data in patients with central PE. METHODS: We retrospectively reviewed data of consecutive patients with central PE diagnosed by CTPA at our institution over a 3 year period. We recorded demographic parameters, clinical findings at presentation, CTPA and echocardiographic data. CTPA and echo measurements of RV size and RV/LV ratio were obtained. Main PA size was obtained from CTPA and evaluation for deep vein thrombosis (DVT) was determined from the venous phase of the CT (CTV). RESULTS: Thirty five patients (16=F) with central PE were identified. Mean age was 58 years (range 31-86).Only 3 patients had hypotension and all improved with iv fluids. EKG showed sinus tachycardia in 88%, S1Q3T3 pattern in 24%, and ST-T-wave changes in 32%. CTPA showed saddle emboli in 4 and bilateral main thrombi in 17 patients. Echocardiograms within 48 hours of CTPA were available in 18 patients. RV/LV ratios were 1.0 or greater on CTPA in 77% of patients and the RV/LV ratio correlated with echo data(r=0.68, p=0.006). PA enlargement (>30mm) by CT was present 67%. Mean PA size was 31 mm (range 25-39). Estimated RV pressure (RVSP) by echo, when available, averaged 44 mm Hg (range 20-69) but there was no correlation between PA size and RVSP. More patients with abnormal EKG's had RV/LV ratio > 1 on CTPA (9/14) than on echo (6/14). Abnormal findings on EKG were not associated with elevated RVSP or RV enlargement on echo. DVT was documented in 17 patients. CONCLUSION: CTPA /CTV provides useful information about RV dilatation and enlargement of the PA, as well as confirming the presence of DVT with a single study. RV enlargement and an RV/LV > 1 on CTPA correlate well with echocardiographic findings and are available without further studies. CLINICAL IMPLICATIONS: In patients with central PE,CTPA can reliably identify RV and PA enlargement and may obviate the need for echocardiogram. DISCLOSURE: Maritza Groth, No Financial Disclosure Information; No Product/Research Disclosure Information

PURPOSE: A review of the diagnostic studies performed in the evaluation of suspected venous thromboembolism (VTE) in obstretical patients at a tertiary care center. METHODS: A retrospective review of all obstetrical patients undergoing either ventilation-perfusion (VQ) scanning, computerized tomographic pulmonary angiography (CTPA), or venous duplex ultrasonography (DUS) over a 3-year period. Demographic information including age, pre- or postpartum status, history of prior VTE and family history of VTE were recorded. RESULTS: Seventy patients were identified. 33 were prepartum and 38 postpartum (1 was evaluated both pre- and postpartum). Thirty-seven had respiratory symptoms. 42 patients had leg symptoms including 8 patients who had both and were included above. All but one prepartum patient underwent DUS (32/33) of which 2 (6%)were positive for deep venous thrombosis (DVT). Seventeen patients had respiratory symptoms: 8 underwent CTPA and one had a VQ scan. Only one study (11%)was positive for pulmonary embolism (PE). Chest radiography was performed in 6 prepartum women with respiratory symptoms. These were normal in 2, in 2 showed pneumonia, effusion in one, and fluid overload in one. In postpartum women, DUS was performed initially in 23 patients of which 2 were positive for DVT (9%). CTPA was obtained in 19 patients and was positive in 2 (10.5%). One patient had a nondiagnostic scan and underwent pulmonary angiography confirming PE. Overall, the incidence of VTE was 9% prepartum and 13.2% postpartum. All but one of the patients with VTE received DVT prophylaxis prior to diagnosis. CONCLUSION: The yield of diagnostic studies for VTE is similar to our non-obstetrical population and higher than in non-pregnant women in this age group. This suggests that VTE is common during and after pregnancy. Pneumonia and fluid overload were also seen frequently in obstetrical patients with symptoms suggestive of thromboembolism. CLINICAL IMPLICATIONS: Given the high maternal mortality of untreated VTE, patients should be thoroughly evaluated, initially with DUS, folowed by chest radiography if there are respiratory symptoms. Those with negative studies should undergo further testing for VTE. DISCLOSURE: Tasbirul Islam, No Financial Disclosure Information; No Product/Research Disclosure Information

PURPOSE: To review the presentation and management of patients with central pulmonary embolism (PE) at a University Medical Center. Central PE was defined as clot in the main pulmonary artery or multiple lobar branches. METHODS: We retrospectively reviewed the records of consecutive patients with central PE detected by CT pulmonary angiography (CTPA). We recorded demographic data, clinical findings at presentation, including heart rate, blood pressure, oxygen saturation, EKG findings, as well as echocardiographic and CTPA evidence of right ventricular dilatation. Treatment options, including thrombolysis, heparin, and inferior vena cava (IVC) filter were noted. RESULTS: Nineteen adult patients with central clot on CTPA were identified. Mean age was 60 years(range 33 to 86) and 10 were females. All patients had evidence of right ventricular (RV) dilatation on CTPA (defined as a ratio of RV/left ventricular (LV)>1.0).Only 4 patients were hypotensive on presentation: 2 corrected with fluids; one had a cardiac arrest shortly after presentation and died in <12 hours; the other was ventilated and on pressors and received tissue plasminogen activator (tPA)with improvement in hemodynamics. Heart rate at presentation was >100/minute in 13 patients (73%). Hypoxemia was present in 13 (73%). Electrogradiographic changes of RV strain were present in 6 patients (32%): three of these patients received tPA.Ten patients also had deep vein thrombosis (DVT)and 8 received IVC filters in addition to anticoagulation. One patient died of underlying extensive malignancy. There were no episodes of recurrent PE prior to discharge. CONCLUSION: Most patients with central clot were not hypotensive even with significant RV dilatation on CTPA, a finding associated with RV dysfunction. A similar rapid clinical resolution was seen in patients treated with either heparin or tPA and no patient required escalation of therapy due to clinical deterioration. CLINICAL IMPLICATIONS: CTPA is a useful tool to detect RV dilatation. The presence of large central pulmonary emboli and RV dilatation alone on CTPA does not indicate the need for thrombolysis, as most patients improved rapidly with routine anticoagulation. DISCLOSURE: Nimrita Dhanjal, None.

Pulmonary embolism (PE) and deep venous thrombosis (DVT) are a continuum and are difficult to diagnose clinically. Combined CT venography and pulmonary angiography (CTVPA) is a single examination that combines multidetector CT pulmonary angiography (CTPA) and CT venography (CTV) of the abdomen, pelvis, and lower extremities, providing "one-stop shopping" for venous thromboembolism without additional venipuncture or i.v. contrast, and it adds only a few additional minutes to scanning time. CTVPA rapidly and accurately examines the deep veins, reveals the presence, absence, and extent of deep venous thrombosis, serves as a baseline, and helps guide patient management. Multiple investigators have reported a high degree of accuracy when CTV is compared with venous ultrasound. There are some pitfalls in image interpretation, especially with regard to mixing artifacts, and there are continuing controversies as to exactly which parts of the abdomen, pelvis, and legs should be scanned routinely, the ideal timing of CTV acquisition relative to contrast injection, and the slice thickness and gap, if any, that should be used.

To determine the feasibility of rapid pleurodesis in patients with malignant pleural effusions in order to reduce hospital length of stay in patients with a limited life expectancy. Prospective case series. Two university hospital programs. Thirty-eight patients with symptomatic pleural effusions associated with malignancy. A 14F catheter was inserted percutaneously into the pleural space after radiographic confirmation of free fluid by lateral decubitus views. Following radiographic confirmation of complete fluid evacuation, a sclerosing agent (ie, talc slurry or bleomycin) was instilled into the pleural space. This was accomplished within 2 h of chest tube insertion, unless the tube was inserted in the evening or if the lung was trapped. After clamping the tube for 90 min, the pleural space was drained for 2 h, after which the chest tube was removed. The intervention was scored as "successful" if no radiographic evidence of fluid reaccumulation was noted at 4 weeks. A "partial successful" score indicated reaccumulation of fluid that did not produce symptoms and did not require repeat pleural drainage of any sort. All other outcomes were scored as "unsuccessful." Measurements and results: Forty chest tubes were inserted into 38 patients. Four procedures revealed the presence of a trapped lung and did not result in any attempt at pleurodesis. Five patients who received pleurodesis died in less than 1 month and therefore were not evaluable. Two patients had technical problems with the chest tube and were not evaluable. Of the remaining 29 procedures, drainage procedures with pleurodesis were performed in 27 patients, a complete response was seen in 14 patients (48%), a partial response was seen in 9 patients (31%), and 6 patients (21%) did not respond to pleurodesis. Chemical pleurodesis was completed as an outpatient procedure in only two patients. In one of these, the outcome was unsuccessful. In the remainder, insertion of the chest tube in the evening or additional medical problems necessitated hospital admission, but the entire procedure was completed within 24 h. Chemical pleurodesis can be accomplished with good results in < 24 h in the majority of patients with malignant pleural effusions.